126
Lerters to the Editor
there is an obstetric indication, and tubal ligation should be rendered if sterilization is requested. Our average hospitalization was 5.25 days, compared with 7.1 days in a North American study [2]. In Trinidad, where bed space is limited, this is a major concern. An intangible advantage is that trainees benefit by participating in the operation under an elective setting, which may prove invaluable when they have to cope with the eventual emergency. Our analysis supports the option of an elective cesarean hysterectomy in women under the circumstances outlined above. We recommend that obstetricians consider this approach when faced with pregnant patients suffering with uterine fibroids. G.V. Nar~~yaushgh S. Ramsewak w. Kissoon
2
3
Park RC, Duffy WP: Role of caesarean hysterectomy in modern obstetric care. Clin Obstet Gynecol23: 601, 1980. Plauche WC, Gruich FG, Bourgeois MO: Hysterectomy at the time of cesarean section: analysis of 108 cases. Obstet Gynecol 58: 459, 1981. Sturdee DW, Rushton DI: Caesarean and postpartum hysterectomy 1968-1983. Br J Obstet Gynecol 93: 270, 1986.
Correspondence
to:
C.V. Narnyansingb Department of Obstetrics and Gynecology University of the West Indies Port of Spain General Hospital Trinidad, West Indies
January
rudimentary uterine horn pregnancy 27th, 1992
A case of noncommunicating rudimentary uterine horn pregnancy is presented. A 20-year-old woman, gravida 2, para 1, was admitted to the hospital in her sixteenth week of gestation because of sudden onset of abdominal pain, nausea and vomiting. She had delivered an immature stillborn infant at 26 weeks of gestation 1 year previously. On admission, there were signs of shock and peritoneal reaction. A tender, 16 weeks pregnant size uterus could be hardly palpated at pelvic examination. A single dead fetus was seen at ultrasonography. The uterine wall could not be demonstrated exactly at the right fundus and a large quantity of fluid was Keyvvordx Uterine rupture; Rudimentary uterine horn pregnancy. Int J Gynecol Obsret 38
1
University of the West Indies Port of Spain San Fernando General Hospital Trinidad
Rupture of noncommunicating To the Editor
References
observed in the abdomen. Detibrinated blood was obtained at culdocentesis. Immediate laparotomy revealed a fetus weighing 600 g with the placenta lying free among the blood and clots. A ruptured right rudimentary horn which was attached to the left hemiuteri with a thick fibrotic band was discovered. No communication between the two cavities was found. Corpus luteum was seen at the right ovary (Fig. 1). Excision of the right rudimentary horn and ipsilateral salpingectomy were carried out. Both kidneys were palpated to be normal, and later a normal intravenous pyelogram was obtained. Five units of whole blood were transfused. Her postoperative convalescence was uneventful. Rudimentary uterine horn pregnancy is rare and its incidence has been estimated between MOO 000 and l/140 000 deliveries [2,4]. Pregnancy can occur only via transperitoneal
Letters to the Editor
Fig. 1.
127
Intraoperative photograph revealing iuptured right rudimentary horn (RH) and the normal left hemiuteri (LH).
migration of the sperm or fertilized ovum. It is usually associated with fetal death. Decreased blood supply, limited uterine distensibility and decreased myometrial contractility are among the causative factors. When the fetus grows, rupture of the uterine wall frequently occurs, resulting in acute intraperitoneal hemorrhage. Rudimentary horn pregnancy seldom results in the delivery of a viable infant [3]. Less than 5% of the reported cases have been diagnosed preoperatively [4]. Previous obstetrical history, such as immature or premature delivery, may also give some clues as to the presence of uterine anomaly. Previous immature stillborn delivery is considered to take place in the left unicornuate uteri. Urinary tract anomalies are associated
with 60% of these cases [l]. Dysmenorrhea is the chief complaint of these patients and endometriosis is the most common additional finding in operative procedures [I]. Despite having a rudimentary horn lined with functional endometrium, our patient had neither dysmenorrhea nor endometriosis at the time of operation. Prompt diagnosis and immediate laparotomy is lifesaving. Surgery should consist of the excision of the rudimentary horn and ipsilateral tube, conserving the ovary. T. B&in U. Demir A. Esmer
Department of Obstetrics and Gynecology Uludag University Medicine Faculty, Bursa Turkey Int J Gynecol Obstet 38
128
Letters to the Editor
References 1
2 3
4
Correspondenceto:
Heinonen PK: Clinical implications of the unicomuate uterus with rudimentary horn. Int J Gynecol Obstet 21: 145, 1983. Johansen K: Pregnancy in a rudimentary born. Obstet Gynecol 34: 805, 1969. O’Grady JP, Salem FA: Rudimentary horn pregnancy with neonatal and maternal survival. J Nat1 Med Assoc 70: 863, 1978. O’Leary JL, O’Leary JA: Rudimentary horn pregnancy. Obstet Gynecol 22: 371, 1963.
Tufan Bilgin Uludsg universitesi Tip Fakiiltesi Kadii Hastaliklari ve D6gum Ann Bilim Dali 16069 Bursa, Turkey
Leiomyoma of the fallopian tube: an unusual cause of abdominal pain
To the Editor
January 27th, 1992
Leiomyoma of the fallopian tube is a relatively rare tumor. This case represents the first such reported in the English speaking Caribbean. A 38-year-old woman of East Indian descent (gravida 6, para 5 + 1) presented with a -day history of severe, cramping, lower ab i ominal pain. Her menstrual period had been due 2 weeks prior to presentation but had actually started on the day before she presented. The pain was described as being unlike her usual dysmenorrhoea and had not been relieved by a 75-mg intramuscular injection of diclofenac (Voltaren, Ciba-Geigy, Basle, Switzerland). The past medical history revealed an ectopic pregnancy 17 years earlier and tubal ligation 8 years prior to presentation. The significant clinical finding was that of lower abdominal tenderness. No masses were palpable. The pain progressively worsened and exploratory laparotomy was performed on the third hospital day. A right tubal mass was seen. Total hysterectomy, right salpingectomy and appendectomy were performed in accordance with the patient’s preoperative wishes. Pathological examination revealed a gross-
KeywordszLeiomyoma; Fallopian tube; Abdominal pain. Int J Gynecol Obstet 38
ly and histologically unremarkable uterus. A smooth, encapsulated, 2-cm diameter mass arose from the cornual end of the fallopian tube compressing the lumen to a slit. Histology of the mass revealed interlacing whorls of smooth muscle fibers typical of a leiomyoma. No ischemic changes were present. The vermiform appendix was unremarkable. Leiomyomas of the fallopian tube are as uncommon as those of the corpus uteri are myriad [I]. The difference in incidence is ascribed to a combination of two factors the abundance of smooth muscle in the corpus and the marked cyclical changes induced in the corpus (including the myometrium) by ovarian hormones, in comparison to the relative nonreactivity of the tubal musculature, even during pregnancy [2]. The fact that this case represents the first such reported in Jamaica, a country with a predominantly black population, underscores the relative rarity of this tumor especially when one considers that leiomyomas of the uterus are more common in black women than in white [3]. Tubal leiomyomas are usually asymptomatic [4]. Those that present clinically are usually large and present either as an adnexal mass or with an acute abdomen consequent on.torsion [2]. Our tumor was unusual in that while small, it presented with acute abdominal pain. The mechanism by which the pain developed might be related to tubal colic secondary to
Lerters to the Editor
there is an obstetric indication, and tubal ligation should be rendered if sterilization is requested. Our average hospitalization was 5.25 days, compared with 7.1 days in a North American study [2]. In Trinidad, where bed space is limited, this is a major concern. An intangible advantage is that trainees benefit by participating in the operation under an elective setting, which may prove invaluable when they have to cope with the eventual emergency. Our analysis supports the option of an elective cesarean hysterectomy in women under the circumstances outlined above. We recommend that obstetricians consider this approach when faced with pregnant patients suffering with uterine fibroids. G.V. Nar~~yaushgh S. Ramsewak w. Kissoon
2
3
Park RC, Duffy WP: Role of caesarean hysterectomy in modern obstetric care. Clin Obstet Gynecol23: 601, 1980. Plauche WC, Gruich FG, Bourgeois MO: Hysterectomy at the time of cesarean section: analysis of 108 cases. Obstet Gynecol 58: 459, 1981. Sturdee DW, Rushton DI: Caesarean and postpartum hysterectomy 1968-1983. Br J Obstet Gynecol 93: 270, 1986.
Correspondence
to:
C.V. Narnyansingb Department of Obstetrics and Gynecology University of the West Indies Port of Spain General Hospital Trinidad, West Indies
January
rudimentary uterine horn pregnancy 27th, 1992
A case of noncommunicating rudimentary uterine horn pregnancy is presented. A 20-year-old woman, gravida 2, para 1, was admitted to the hospital in her sixteenth week of gestation because of sudden onset of abdominal pain, nausea and vomiting. She had delivered an immature stillborn infant at 26 weeks of gestation 1 year previously. On admission, there were signs of shock and peritoneal reaction. A tender, 16 weeks pregnant size uterus could be hardly palpated at pelvic examination. A single dead fetus was seen at ultrasonography. The uterine wall could not be demonstrated exactly at the right fundus and a large quantity of fluid was Keyvvordx Uterine rupture; Rudimentary uterine horn pregnancy. Int J Gynecol Obsret 38
1
University of the West Indies Port of Spain San Fernando General Hospital Trinidad
Rupture of noncommunicating To the Editor
References
observed in the abdomen. Detibrinated blood was obtained at culdocentesis. Immediate laparotomy revealed a fetus weighing 600 g with the placenta lying free among the blood and clots. A ruptured right rudimentary horn which was attached to the left hemiuteri with a thick fibrotic band was discovered. No communication between the two cavities was found. Corpus luteum was seen at the right ovary (Fig. 1). Excision of the right rudimentary horn and ipsilateral salpingectomy were carried out. Both kidneys were palpated to be normal, and later a normal intravenous pyelogram was obtained. Five units of whole blood were transfused. Her postoperative convalescence was uneventful. Rudimentary uterine horn pregnancy is rare and its incidence has been estimated between MOO 000 and l/140 000 deliveries [2,4]. Pregnancy can occur only via transperitoneal
Letters to the Editor
Fig. 1.
127
Intraoperative photograph revealing iuptured right rudimentary horn (RH) and the normal left hemiuteri (LH).
migration of the sperm or fertilized ovum. It is usually associated with fetal death. Decreased blood supply, limited uterine distensibility and decreased myometrial contractility are among the causative factors. When the fetus grows, rupture of the uterine wall frequently occurs, resulting in acute intraperitoneal hemorrhage. Rudimentary horn pregnancy seldom results in the delivery of a viable infant [3]. Less than 5% of the reported cases have been diagnosed preoperatively [4]. Previous obstetrical history, such as immature or premature delivery, may also give some clues as to the presence of uterine anomaly. Previous immature stillborn delivery is considered to take place in the left unicornuate uteri. Urinary tract anomalies are associated
with 60% of these cases [l]. Dysmenorrhea is the chief complaint of these patients and endometriosis is the most common additional finding in operative procedures [I]. Despite having a rudimentary horn lined with functional endometrium, our patient had neither dysmenorrhea nor endometriosis at the time of operation. Prompt diagnosis and immediate laparotomy is lifesaving. Surgery should consist of the excision of the rudimentary horn and ipsilateral tube, conserving the ovary. T. B&in U. Demir A. Esmer
Department of Obstetrics and Gynecology Uludag University Medicine Faculty, Bursa Turkey Int J Gynecol Obstet 38
128
Letters to the Editor
References 1
2 3
4
Correspondenceto:
Heinonen PK: Clinical implications of the unicomuate uterus with rudimentary horn. Int J Gynecol Obstet 21: 145, 1983. Johansen K: Pregnancy in a rudimentary born. Obstet Gynecol 34: 805, 1969. O’Grady JP, Salem FA: Rudimentary horn pregnancy with neonatal and maternal survival. J Nat1 Med Assoc 70: 863, 1978. O’Leary JL, O’Leary JA: Rudimentary horn pregnancy. Obstet Gynecol 22: 371, 1963.
Tufan Bilgin Uludsg universitesi Tip Fakiiltesi Kadii Hastaliklari ve D6gum Ann Bilim Dali 16069 Bursa, Turkey
Leiomyoma of the fallopian tube: an unusual cause of abdominal pain
To the Editor
January 27th, 1992
Leiomyoma of the fallopian tube is a relatively rare tumor. This case represents the first such reported in the English speaking Caribbean. A 38-year-old woman of East Indian descent (gravida 6, para 5 + 1) presented with a -day history of severe, cramping, lower ab i ominal pain. Her menstrual period had been due 2 weeks prior to presentation but had actually started on the day before she presented. The pain was described as being unlike her usual dysmenorrhoea and had not been relieved by a 75-mg intramuscular injection of diclofenac (Voltaren, Ciba-Geigy, Basle, Switzerland). The past medical history revealed an ectopic pregnancy 17 years earlier and tubal ligation 8 years prior to presentation. The significant clinical finding was that of lower abdominal tenderness. No masses were palpable. The pain progressively worsened and exploratory laparotomy was performed on the third hospital day. A right tubal mass was seen. Total hysterectomy, right salpingectomy and appendectomy were performed in accordance with the patient’s preoperative wishes. Pathological examination revealed a gross-
KeywordszLeiomyoma; Fallopian tube; Abdominal pain. Int J Gynecol Obstet 38
ly and histologically unremarkable uterus. A smooth, encapsulated, 2-cm diameter mass arose from the cornual end of the fallopian tube compressing the lumen to a slit. Histology of the mass revealed interlacing whorls of smooth muscle fibers typical of a leiomyoma. No ischemic changes were present. The vermiform appendix was unremarkable. Leiomyomas of the fallopian tube are as uncommon as those of the corpus uteri are myriad [I]. The difference in incidence is ascribed to a combination of two factors the abundance of smooth muscle in the corpus and the marked cyclical changes induced in the corpus (including the myometrium) by ovarian hormones, in comparison to the relative nonreactivity of the tubal musculature, even during pregnancy [2]. The fact that this case represents the first such reported in Jamaica, a country with a predominantly black population, underscores the relative rarity of this tumor especially when one considers that leiomyomas of the uterus are more common in black women than in white [3]. Tubal leiomyomas are usually asymptomatic [4]. Those that present clinically are usually large and present either as an adnexal mass or with an acute abdomen consequent on.torsion [2]. Our tumor was unusual in that while small, it presented with acute abdominal pain. The mechanism by which the pain developed might be related to tubal colic secondary to
